RESIDUAL RIDGE

RESORPTION
DR. AATIF KHAN
• Definitions
• Classification
• Pathology
• Pathogenesis
• Epidemiology
• Etiology
• Prevention
• Treatment
• Summary and conclusion
DEFINITIONS
Residual bone – That component of the maxillary or mandibular bone that remains after the teeth are lost.
(GPT 9)

Residual ridge – The portion of the residual bone and its soft tissue covering that remains after the
removal of teeth. (GPT- 9)

Residual ridge crest – The most prominent continuous surface of the residual ridge, not necessarily
coincident with the center of the ridge. (GPT – 9)

Residual Ridge Resorption – A term used for the diminishing quantity and quality of the residual ridge after
the teeth are extracted. (GPT – 9)
RESIDUAL ALVEOLAR RIDGE -

Maxilla Mandible
The residual bony architecture of the maxilla and mandible undergoes a life-long
catabolic remodelling.

The rate of reduction in size of the residual ridge is maximum in the first
3-6 months and then gradually slows down.

However, bone resorption continues throughout life at a slower rate, resulting in

loss of varying amount of jaw structure, ultimately leaving the patient a ‘dental
cripple’.
 Pre
extraction Post ext High well rounded

According to Atwood :
(JPD 1971 Vol.26)

 Order 1 : Pre-extraction
 Order 2 : Post-
extraction
 Order 3 : High, well
rounded
 Order 4 : Knife-edge
 Order 5 : Low, well
rounded
 Order 6 : Depressed
Knife edge Low well rounded Depressed
 Class I : Upto one third of the original vertical
height lost.
 Class II : From one third to two thirds of the
vertical height lost.
 Class III : Two third or more of the mandibular
height lost.
 Based on Bone Height (Mandible only)
 Type I : Residual bone height of 21 mm or greater
measured at the least vertical height of the mandible.

 Type II : Residual bone height of 16 - 20 mm measured

at least vertical height of the mandible.

 Type III : Residual alveolar bone height of 11 - 15 mm

measured at the least vertical height of the mandible.

 Type IV : Residual vertical bone height of 10 mm or less

measured at the least vertical height of the mandible.
According to Cawood and Howell -

• Class I - dentate.
• Class II - immediately post extraction.
• Class III- well-rounded ridge form,
adequate in height and width.
• Class IV - knife-edge ridge form,
adequate in
height and inadequate in width.
• Class V - flat ridge form, inadequate
in height and width.
• Class VI - depressed ridge form,
with some basalar loss evident.
A classification of the edentulous jaws. Int. J. Oral Maxillofac.
Surg. 1988; 17:232-236
PATHOLOGY OF RRR -
PATHOLOGY OF RRR -

 Immediately following the extraction (Order II), any sharp edges remaining are
rounded off by external osteoclastic resorption leaving a high well rounded ridge
(Order III).

As resorption continues from the labial and lingual aspects the crest of the ridge
becomes increasingly narrow, ultimately becoming knife edged (Order IV).

As the process continues, the knife-edge becomes shorter and eventually disappears
leaving a low well-rounded or flat ridge (Order V). Eventually this too resorbs, leaving a
depressed ridge (Order VI).
PHYSIOLOGY VS PATHOLOGY -

 Some clinicians feel that RRR is not a disease but a normal physiological process.

However there is wide variation in the rate of RRR in different individuals- depending
on multiple factors.

The need to explain these major differences warrants labeling this process a
“disease” or “pathology”.
Based on the clinical facts :
•RRR is not inevitable

•Its rate varies in people

•The rate of resorption is greater that the rate of

formation in some patients

Therefore, RRR should be considered a pathologic process.

 HIGH WELL
POST- ROUNED
EXTRACTION

KNIFE
LOW WELL EDGED
ROUNDED
• The most striking feature of the extraction wound healing is that even after the
healing of wounds, the residual ridge undergoes a lifelong catabolic remodeling.

• This unique phenomenon has been described as RESIDUAL RIDGE RESORPTION

(RRR).

• The rate of RRR is different among persons and even at different sites in the same
person.
Coupled process between:
Bone deposition by osteoblasts and,
Bone resorption by osteoclasts
5-7% of bone mass is recycled weekly
All spongy bone replaced every 3-4 years.
All compact bone replaced every 10 years

Prevents mineral salts from crystallizing; protecting

against brittle bones and fractures
Gross Microscopic
A frequent lay expression - “ My gums have shrunken”, RRR Is primarily a localized loss
of bone structure.

In some cases it may leave excessive and redundant overlying mucoperiosteum and in
some cases it may not.

“One factor in RRR may be a cicatrizing mucoperiosteum that is seeking a reduced area,
resulting in pressure resorption of the underlying bone” - Lammie
• External cortical surface of maxilla and mandible are uniformly smooth & crestal
area of residual ridge shows porosities and imperfections.

• Bones with more severe RRR display gross porosities of medullary bone on the
crest of ridge.
 Panoramic radiograph showing severe RRR in both maxilla
and mandible in contrast to dentulous area that support
three mandibular teeth.
• Microscopic studies have revealed
Osteoclastic activity on the
external surface of crest of ridges .

• Scalloped margins of Howships

lacunae sometimes contain visible
osteoclasts.

• Frequently the scalloped

external surface seems
inactive without visible
bone resorbing cells and is
covered by fibrous non-
osteogenic periosteum.
 Incompletely
closed osteon

Increased
endosteal
porosity Varying
density

A microradiograph of the inferior border of a mandible showing

evidence of moderate osteoporosis with increased variation in the density of osteons, increased
number of incompletely closed osteons, and increased endosteal porosity ( x 15)
HISTOLOGICAL PATTERN OF BONE FORMATION
IN EXTRACTION SOCKET

1 2 3 4
PATHOGENESIS OF RRR -

Attachment of osteoclasts to mineralized surface of bone

Creation of a ruffled border and a sealed acidic

environment through action of the proton pump

Dissolution of the Hydroxyapatite

Fall in pH to 2.5-3 in the osteoclast resorption space

Digestion of the organic components of the matrix by

proteolytic enzymes
 1. Serial examination of diagnostic casts.

2. Lateral cephalometric radiographs -

◦ Most accurate
◦ Measure RRR over a period of time.
{Kenneth E. Wical and Charles C. Swoope. Studies of residual ridge resorption. Uses panaromic radiographs for evaluation and
classification of mandibular resorption. (JPD;1974;32;7}
 EPIDEMIOLOGY OF RRR:

•To date, it appears that RRR is world-wide, occurs in males and

females, young and old, sickness and in health, with and
without dentures and is unrelated to the primary reason for the
extraction of the teeth (Caries / periodontal disease).
• Rate of RRR is variable -
-between persons.
-within the same person at different times.
-within the same person at different sites.
‘Tallgren’ and ‘Atwood and Coy’ conducted separated studies in different parts
of the world, and found that the mean ratio of anterior maxillary RRR to anterior
mandibular RRR was 1:4.
However, there were exceptions to this mean, with a greater RRR in the maxilla
in some patients with insignificant RRR in either jaw in some patients.

The reverse may be true in any given patient coming for treatment.
According to Boucher,

• During the first year after tooth extraction, the reduction in residual ridge
height in the midsagittal plane is –

• 2-3 mm for maxilla and 4-5 mm for mandible

 PATTERN OF BONE RESORPTION -

✓ Maxilla resorbs upward and inward to become

progressively smaller because of the direction and
inclination of the roots of the teeth and the alveolar
process.

The opposite is true of the mandible, which

inclines outward and becomes progressively
wider.
•Thus, RRR is centripetal in maxilla and centrifugal in mandible.
 PATTERN OF BONE RESORPTION -

In the Mandible, large proportions of bone loss occurs in the -

✓ labial side of anterior residual ridge,
✓ equally on the buccal and lingual side in premolar
region and
✓ lingually in the posterior or molar region.

In comparison, in the Maxilla, bone loss primarily occurs on the labial or

buccal aspect.
Resorption pattern of alveolar bone :
MAXILLA

MANDIBLE
 CLINICAL IMPLICATIONS -
• While teeth arrangement we should try to restore the natural position of the teeth
before they were lost, Hence teeth in the maxillary arch are arranged slightly labially
and buccally.

• While in the mandible, teeth in the anterior region are arranged labially, on the centre
of the ridge in the premolar region and slightly lingually in the molar region.
 Maxilla V/s Mandible
 It is a clinically acknowledged fact that the anterior mandible resorbs 4 times
faster than the anterior maxilla.

Woelfel et al have cited the projected maxillary denture area to be 4.2 sq in. and
2.3 sq in. for the mandible; which is in the ratio of 1.8:1.

If a patient bites with a pressure of 50 lbs, this is calculated to be 12 lbs/sq in.

under the maxillary denture and 21 lbs/sq in. under the mandibular denture.
The significant difference in the two forces may be a causative factor to cause a
difference in the rates of resorption.
 Maxilla V/s Mandible
 Cancellous bone is ideally designed to absorb and dissipate the forces it is
subjected to.

The maxillary residual ridge is often broader, flatter, and more cancellous than
the mandibular ridge.

Trabeculae in maxilla are oriented parallel to the direction of compression,

allowing for maximal resistance to deformation.

The stronger these trabeculae are, the greater is the resistance.

- RRR is chronic, progressive, irreversible, and
cumulative.

- Autonomous regrowth has not been reported.

- Generally more in mandible than in maxilla but the reverse may also occur.

- So one must treat every patient as a “PARTICULAR PATIENT, NOT THE AVERAGE
PATIENT!”!
 Acc. To Atwood… {Some clinical factors related to rate of
resorption of residual ridges JPD Vol 12,issue 3, pages
441-450.
RRR is a multifactorial biomechanical disease
caused by a combination of
◦ ANATOMIC FACTORS
◦ MECHANICAL FACTORS
◦ METABOLIC FACTORS
 It is postulated that RRR varies with the quantity and
quality of the bone of residual ridges..
RRR α Anatomic factors

ie, the more bone there is, the more RRR will ultimately be.

But the amount of bone cannot be considered a good prognostic

factor, because in some cases large ridges resorb rapidly and
some knife-edge ridges may remain with little change for long
periods of time.
• We should always try to evaluate the present status of the
residual ridge to determine what has gone on before, i.e,

• Another way to evaluate the anatomic factors is to consider

the mechanical factors that would be favorable to stability
and retention of a denture.

• Density of bone.
 RRR varies directly with certain systemic or
localized bone resorptive factors and inversely with
certain bone formation factors.

RRR  BONE RESORPTION FACTORS

BONE FORMATION FACTORS
 BONE RESORPTION FACTORS

LOCAL SYSTEMIC

- Endotoxins from dental plaque - Correct amount of circulating

- Osteoclast activating factor(OAF) estrogen, thyroxine, growth hormone,
calcium, phosphorus,
- Prostaglandins
- Vitamin D
- Human gingival bone resorption
Factor - Osteoporosis
- Heparin associated with mast cells
- Parathormone
- Trauma due to ill fitting dentures which
leads to increased or decreased - Calcitonin
vascularity and changes in oxygen tension. - Hypophosphatemia
• Bone has its own specific metabolism and undergoes equivalent changes.
• The four main levels of bone activity are
equilibrium,
growth,
atrophy, resulting from decreased osteoblastic activity, as in osteoporosis and
in disuse atrophy, and
resorption, caused by increased osteoclastic activity, as in hyperparathyroidism
and in pressure resorption
• - The degree of absorption of Ca, P and proteins determines the amount of
building blocks available for the growth and maintenance of bone.
• - Vit C aids in bone matrix formation.
• - Vit D acts through its influence on the rate of absorption of calcium in the
intestines and on the citric acid content of bone.
• -Various members of Vit B complex are necessary for bone cell
metabolism.
 Residual ridge resorption of the jaws is also more
rapid in increasing age group, depleted bone being
prone to the injurious impact of mechanical forces.
• Bone that is used by regular physical activity will tend to strengthen within certain
limits, than the bone that is in “disuse atrophy”, while others have postulated that
due to denture wearing RRR is caused due to an “abuse” bone resorption.

• Perhaps there is truth in both the hypotheses.

• The fact is that with or without dentures some patients have little or no RRR and
some have severe RRR.
FORCE FACTORS
RRR α Force

The amount of force applied to the bone may be affected inversely

by the damping effect or energy absorption.

1
RRR α ———————-
Damping effect
The damping effect is due to the viscoelastic
property of the mucoperiosteum and may vary from
patient to patient and also from maxilla to mandible.

Cancellous bone helps in the absorption and

dissipation of forces and is more in maxilla than
mandible, which could be a reason in the
difference in RRR between them.
MEHANICAL / PROSTHETIC FACTORS -
• Excessive stress resulting from artificial environment.

• Abuse of tissues from lack of rest –

• Bone is moldable. It can tolerate masticatory forces within the

limits of physiologic tolerance.

• But exceeding that it causes damaging forces which will result in

resorption of the alveolar bone.
• Long continued use of ill fitting dentures: Long use, Loss of bone, Incorrect
occlusion, Incorrect jaw relation
• Lack of freeway space due to increased vertical dimension of occlusion:
• Freeway space is present in the teeth in the physiologic rest position. It is
normally around 2mm.
• At times, due to lack of freeway space the bone resorbs because of increased
vertical height in an attempt to create the space.
➢ Incorrect Centric relation record: If the Centric relation is not recorded properly, the
mandibular teeth will not occlude properly with those on the maxillary arch. This
proper occlusion is essential to the health of bony support.

• Otherwise, during eccentric movement, it causes pressure on bone due to failure of

denture stability. Hence resorption of base occurs.
➢ If occlusal corrections are not done:
• These errors which may be caused due to processing
techniques if not corrected causes premature contacts
resulting in increased stress.

• Selective grinding should be done to minimize lateral stress and resulting tissue
trauma.
Kelly first described the “combination syndrome”
wherein patients with remaining mandibular natural
teeth against a maxillary complete denture were
shown to have an exaggerated loss of anterior
segment of maxillary residual ridge.
 In addition to the 3 major categories of factors
(anatomic, metabolic and mechanical), the
importance of time since extraction is also
important. This can be added to the formula by an
inverse relation -

factors Bone resorption factors Force

RRR α anatomic factors 1
——— + + ———————————— + ———— + ——
Time
Damping
Bone formation factors
effects
 Apparent loss of sulcus width and depth.

Displacement of muscle attachment close to the ridge.

Loss of vertical dimension of occlusion.

Reduction of the lower face height.

Increase in relative prognathism.

 Changes in inter alveolar relationship.

Morphological changes of the alveolar bone such as sharp,

spiny uneven residual ridges.

Location of mental formina close to the ridge crest.

 “Treatment of RRR is ideally by preventing it.”

a. Prevention of loss of natural teeth:

Alveolar bone supporting natural teeth receives
tensile loads through a large area of periodontal
ligament.

While the edentulous residual ridge receives

vertical, diagonal and horizontal loads applied by a denture with
a surface area much smaller than the total area of the
periodontal ligament of all the natural teeth that had been
present.
 ❑ Optimal tissue health prior to making impression.
❑ Impression procedures -
❑ -Minimal pressure impression technique.

-Selective pressure impression technique: places stress on those areas

that best resist functional forces
-Adequate relief of non stress bearing areas.
eg. Crest of mandibular ridge.

- Broad area of coverage helps in reducing the force /unit area(Snow Shoe
Effect)
❑ Avoidance of inclined planes to minimize dislodgment of
dentures and shear forces.

❑ Centralization of occlusal contacts to increase stability and

maximize compressive forces.

❑ Provision of adequate tongue room to improve stability of

denture in speech and mastication.

❑ Adequate interocclusal distance during jaw rest to decrease the

frequency and duration of tooth contact.

❑ Occlusal table should be narrow -

The concept and arrangement of teeth in neutral zone helps the
teeth to occupy a space determined by the functional balance of
the oro- facial and tongue musculature.
 It has been seen that one of the cofactor in RRR is
low calcium and vitamin D metabolism.

Diet counseling for prosthodontic patients is

necessary to correct imbalances in nutrient intake.

Denture patients with excessive RRR report lower calcium

intake and poorer calcium phosphorus ratio, along with
less vitamin D.
 Excessive RRR leads to loss of sulcus width and depth with
displacement of muscle attachment more to the crest of
residual ridge.

Osseous reconstruction surgeries, removal of high frenal

attachments, augmentation procedures, vestibulo-plasties
etc may be required to correct these conditions.
 Inferior Border Augmentation

 Superior Border Augmentation

 Interpositional Grafts
e. Immediate dentures:
Some authors claim that extraction followed by
immediate dentures reduces the ridge resorption.
 f. Overdentures

✓ Tooth supported over dentures help in improved

stress distribution there by maintaining the integrity
of residual ridge.

✓ The occlusal and parafunctional stresses are

distributed through the abutment teeth.

✓A study was conducted with overdentures supported by canines and it was

seen that, the bone loss was 0.6mm where as 5mm in conventional complete
dentures.
 The introduction of osseointegrated implants has eclipsed traditional
preprosthetic surgical techniques. The use of implant-supported
overdentures resembles the same clinical situation of teeth supported
overdentures.
 Metal based dentures {JPD 1987 ;57:6 }

 Metal based denture with soft liner is advocated in patients with severely atrophic
residual ridges.

Metal base provides-

◦ Weight necessary to facilitate retention
◦ Maintain Adequate strength with modest extensions

The soft liner accomodates ridge irregularities and changes.

PRECAUTIONS TO REDUCE RRR -
During extractions –
The labial plate should be preserved when tooth is removed.

The labial periosteal covering should remain intact as its inner layer is
responsible for remodeling of bone.

If bone has to be removed, it must be the palatal plate.

 The ultimate aim of a successful prosthesis is stability in function and
excellent esthetics.

The expectations of edentulous patients are highly variable therefore the outcome
of patient treatment varies significantly.

Patients should be educated regarding the type and extent of treatment that is ideal
for them, the prognosis of the treatment outcomes with various types of removable
or fixed prostheses and the alternatives that are available.
REFERENCES -
Essentials of Complete Denture Prosthodontics (Second edition) - Sheldon
Winkler
Compilation of notes